Thursday, February 26, 2015

The Ethics of Prediction

Predicting the future is probably the most valuable trick in the book. Well, maybe ACCURATELY predicting the future is the most valuable trick in the book, though a lot will still depend on who you’re trying to sell the book to. But if we knew the future, we would know not only that a sucker is born every minute, but also where and how fast. This is known as Heisenberg’s "circussy" principle.

We’re all familiar with one of the oldest tricks in the book: Insurance. Hell yeah, we want to know when we’re going to die so someone can bet us we’re not gonna. But despite the fact that your genetics and your family history are no longer admissible factors in eligibility for health insurance and employment, those snake eyes can see you right out of life and long term disability insurance, so you would have to be some of the people all of the time to play these odds.

This kind of gaffe really only works in your favor if you have the kind of dark secret Daphne Du Marier would have considered melodramatic. Insurance companies want to know how much they are probably going to have to shell out for you, how much more you are going to shell out to them, how hopeful they can be that you will be stabbed to death in the shower (which in insurance circles is considered the best possible outcome for everyone but you, and is thereby an ethical object of hope), and how long they can keep this outrageous racket up in a society of polysyllabic individuals, many of whom are capable of using tools and detecting the drawbacks of pissing into a sieve. At least I used to think so.

Some of the predictions that can be used to charge you money for insurance may incidentally be relevant to your health. This may be the one thing you want to know about as much as the people who want to sell you discount pacemakers and cremation packages. Unfortunately, these predictive tests are not as reliable as we would like. We can’t predict all outcomes with consistent regularity, and often we’re not quite sure which variables contribute to health outcomes. What happens when we tell you you’re going to die and you don’t? Talk about disappointing. People could go to jail for less! 

Which reminds me that they do.

Of course crimes are downright terrible. Obviously all crime should stop immediately, because it is against the law. Sure, it could make a lot of difference if we knew what caused a crime to be committed. Predicting incidence and recidivism makes a lot of sense. We could stop bad things from happening! The idea of taking a preventative approach to crime rather than a punitive one sounds lovely in theory, until you think about how we would actually do it. It certainly doesn't make sense to lock people up before they can commit crimes; and following an indicated individual until they eventually offend smells a little like entrapment, and definitely strikes me as unsportsmanlike. And would it even work?

How well can we predict these things? An integral aspect of any ethics assessment is a frank exploration of the efficacy or reliability of what is being assessed. In the case of predictive data, like with other prognostication, the answer is: It depends. I know, sorry. But if you say it in a fun mystical voice, it helps.

To make predictions for insurance agencies, we turn to a cold and ancient race of humanoids called “actuaries.” (Editor’s note: There are no facts in this paragraph.) Actuarial science is the inevitable product of ghastly pale dweebs rubbing their long fishy fingers together and hoping a piano falls on your head. At least I think so, and I already looked up way too much information for this post to bother checking this one out. Get out of here, you bloodless fiend! Anyone who is delighted to give me odds against my own defenestration or gleefully monitoring my day drinking can just take whatever numbers they’re excreting and shove them back up their asses. No thank you! 
(UPDATE: Whoops, looks like I confused "Actuary" with "Uriah Heep"? Not sure why. Sorry if you are an actuary, or whatever.)

Discussing predictors in health is trickier than just summarily dismissing an entire profession, because I happen to know slightly more than jack shit about it. Genetic testing and sequencing can provide insights into conditions that you may develop later in life that you might not have now, such as Huntington's, breast cancer, Alzheimer’s, and Parkinson’s. However, some of these traits are incompletely understood but known to be multi-factorial (involving more than one gene or exposure), which makes a reliable prediction of risk complicated. This makes many providers reluctant to offer these tests, since there is concern that these results could adversely impact health by erroneously influencing decision making, or causing undue alarm when there is no cause for concern.

Our method for predicting crime is even more bizarre, because we have been using measures about as efficacious as a splint on a shit for DECADES and we don’t even care. Moreover, we have more recently begun employing these variably useless measures to determine who can just get out of an overcrowded jail free, and who needs to serve out their sentences, as if this makes any goddamn sense at all. Most surveys designed to predict repeat criminal behavior are reliant on self-report data, both for the individual they are assessing, and the aggregate patterns they identify. This means that all of the things we think we know about the behavior of people in jail comes from what people in jail tell us.

N.B. I am not suggesting that people in jail are less reliable than other people (I’ll leave that to the courts), but I do recall that in high school I took a fiendish delight in derailing official surveys, and I don’t think that it is beyond the bounds of possibility that incarcerated people might demonstrate at least comparable delinquency to your average high school student. 

So just how accurate are these predictors? One moribund study from an era in which LEAD WAS STILL PLAYING A SIGNIFICANT ROLE IN CRIMINALITY suggests that these surveys can predict repeat crime with up to 70% reliability, though it is worth noting that the crime rate in the 1980s was the highest in U.S. history and so it was a pretty safe bet to assume that EVERYBODY was going to break the law eventually. Given that inconsistent variables, methods, and most importantly, transparency have made an overall judgment of this predictive measure impossible, it remains unclear whether or not these analytics contribute anything of value, or if, perhaps, they result in greater damages than they prevent. 

Prisons are horrifically over-crowded, contributing to rising costs that are exceeding 70 BILLION DOLLARS per year. A 2007 National Institute of Corrections sponsored policy analysis suggests that prison populations could be reduced by up to 50% by limiting incarceration for parole and non-violent violations, and reducing mandatory sentencing for low level crime like drug sales. Why are so many people in jail?

Some schools of thought surrounding criminality assume a significant genetic component to deviant behavior. While there are some genetic disorders that are associated with violent behavior, such as the Y chromosome, there is no evidence of any "aggression" gene that operates to escalate violent tendencies in individuals. This makes sense, since as noted above, most complex traits are multi-factorial. But aside from the factual irrelevance, could genetic predictions about criminality be harmful?

The concerns that we have about predictive tests in health are analogous to many of the concerns that arise about predictions anywhere. First of all, what if the test is wrong? If the outcome we predict is “Criminality,” an individual may be unjustly stigmatized. We also worry about compromising what is known as an “open future.”

To have an “open future” means to have one that has not been narrowly defined by external forces, or rather, MORE narrowly defined than it is already. Our ascribed characteristics such as our race, our class, and our social context can define our future more cogently than a deadly disease, of course, but there is something unnecessarily fatalistic about forecasting a hideous demise. One of the primary arguments against testing children for adult onset disorders like Huntington’s is the concern that this information will circumscribe a child’s options, and that a life may be lived differently with this knowledge. (Of course, if you use slightly different words this is also an argument for testing children, and now you know why people in ethics are such assholes all the time.)

There is also the concern that these predictions contribute negatively to the self-concept and identity of the individual, by defining them as “sick,” “criminal,” or “disabled.” We know that labeling can be harmful. By predicting relapses in criminal behavior, are we also encouraging it? An individual whose future has already been defined by poverty and racism may have no choice but to accept an identity further narrowed by predictions of criminal behavior.

It is also worth noting that predictive tests have implications for family members as well as individuals. Genes and environment are often shared, so it is not unlikely that these predictions could have relevance to others. 

Many, many others. 

The United States has more incarcerated criminals than any other country. With over 2.2 million individuals in prison, that's a lot of families, and a lot of stakeholders. That's a lot of people that these arbitrary predictions may be influencing, and it's worth thinking about who those people are. 

Of the 2.2 million people in our prison system today, an overwhelmingly disproportionate number are minorities. While there are numerous factors advanced for this disparity, the fact remains that the prison population is not representative of the overall population, and instead is inequitably representative of minorities and persons living in poverty.  With predictions that can influence such a disproportionate number of individuals, and their families, it makes sense to wonder who is making these predictions, and how they are being made. 

This is a process that is contributing to the subjugation of a lot of people. Who is responsible for it? In a way, we all are. We pay the taxes that fuel the justice system (over 70 BILLION dollars a year!), and we elect the judges that keep the system running. We pay taxes that support universities and public institutions, but the research that they produce often sits behind a pay wall, or is presented in a forum we don't have access to. But this research is informing these policies, and we are at a loss to understand why. We can ask. We can ask our elected representatives to be more transparent about the policies and practices behind parole and risk assessment, and we can look at statistics like this one, that say the average prison time served by an African American for a drug offense (58.7 months) is nearly the equivalent of the average prison term served by whites for violent offenses (61.7 months.) 

To say that this is an appalling disparity is anemic. We are not required to passively allow a harmful, discriminatory power differential to perpetuate itself, and we are certainly not required to pay for it. Furthermore, if we can predict trends in crime, doesn't that suggest that we are developing a more nuanced understanding of the factors that influence crime? Why wouldn't we focus on mitigating those factors as opposed to predicting recidivism in individuals? if we already have this information, it seems to me that we could be finding more responsible applications for it. 

Thursday, November 20, 2014

Safe Travels

Five days after I was raped I flew to Boston. The security lines were endless, claustrophobic, and humming with the restless panic of herds before a lightning storm. I took off my shoes and my belt, and walked through the metal detector. A shrill alarm went off, and a security guard shoved me forward towards a female guard for additional screening. She slid her arm roughly up the inside of my thigh and I jerked away. She grabbed me by the arm and asked me if I had a problem. Did I? She asked. She sneered down at me.  Did I? Did I have some kind of problem? Did she need to get a supervisor to address my complaint or report my uncooperative behavior?
This was in 2001, when travelers were so cowed by the need for security measures in airports we would submit to any indignity without complaint. To be uncooperative was to be suspicious, and to arouse suspicion was terrifying.

No, I said. Of course not.

In 2004, I was traveling across Europe with some friends. We wandered out of our car looking for a covert place to sneak an illicit cigarette. At the far end of the train was a car that at first glance seemed unoccupied, but which was soon revealed to contain two male backpackers lying across two separate rows of seats, studiously avoiding eye contact with one another and masturbating furiously.
My friend and I stood there, aghast. They looked at us, looked us up and down. They didn't stop. One of them said, "Hey, you can't smoke in here."

My intention in relating the above anecdotes is not to advocate that we be more assertive with the TSA, or that more people should be allowed to smoke on trains. I would like to be clear that neither of these activities are healthy. But for me, almost fifteen years later, neither are airports and neither are trains. Airport security gives me the screaming jeebies. A bunch of angry people in uniforms usher you humorlessly into a grim little oubliette where you stand in a defenseless, ridiculous posture while an invisible robot smells your ass to see if you're carrying anthrax or incendiaries, and on the other side they give you the gropes to be sure that your underwire bra doesn't convert to a ground cannon. This gives me the pukes.

I don't want to do things that give me the pukes, but I sometimes have to. This is the same kind of dilemma we see evinced in all decisions that are made by agencies on our behalf to protect populations. Unilateral mandates, like seat belt laws, transportation security measures, and water fluoridation are things that we are subjected to, often in violation of our autonomous interests, because they are considered to be in the interest of greater good for the population. I can't disagree with this. I support vaccines, because I do not want to die bleeding out my eyes if there is any possible way to avoid this. And so by the same token, I support transportation security measures, because I want to feel safe when I travel.

Except I don't feel safe.

One of my favorite feminists wrote this incredible piece about a recent experience on a train in Scotland. She and another female traveler, after being harassed with insults that escalated to threats of violence and rape, were advised that they should have changed seats or complained to a (non-existent) employee. No one intervened.

For our safety, we are advised not to leave our bags unattended, because they will be subject to seizure and search. We are advised not to lock our bags, because this will make it more difficult for the bags to be inspected, for our safety. We are advised to hold still, with our arms above our heads, while complete strangers run their hands over our breasts and between our legs, for our safety. And we agree to these compromises of our autonomy in the interest of contributing to the overall safety of our environment.
But who bears the ultimate responsibility for our safety when we travel? Most seat pockets contain safety information, and some variation on the assurance that our safety is the primary concern of <insert business here>. But whose safety?  And what are we being protected from?

A few years ago, I sat on a plane next to an aggressive drunk who spent the entire four hour flight relentlessly supplying me with details about his penis, and some limited perseverations on the theme of his ex-wife (a "Real cunt"). He leaned over my seat, slurring broken heartedly about his vasectomy. He squeezed my purse, mistakenly believing it was my thigh. He asked intrusive questions.
"Excuse me," I said politely. You have to be polite, because if you are not, you are a bitch. You are not firm, or severe, or forbidding. You are not assertive or clear. You are a real cunt, and this is inadvisable, because nothing is going to piss this guy off like a real cunt. We all know not to provoke predators. And so, smilingly, I said, "Would you mind giving me a little more space? I'm feeling a little claustrophobic."

He said, "You don't need to be such a bitch about it."

For the rest of the flight, he monopolized the armrest. He pretended not to hear me when I asked to use the bathroom, forcing me to squeeze past his legs and lap. He slumped against me while his hand scrabbled against the seat, searching blindly for my leg. He sat too close.
Perhaps I should have asked to move. Perhaps I should have asked a flight attendant for help. But the flight was full. The intervention of the flight attendant would only have escalated the situation. And so I sat there, for hours, while this man menaced me. I did not feel safe.

When we participate in the security theater, we are doing it with the understanding that we can all contribute to making travel safer and more comfortable for everyone. But the issues we prioritize give us a lot of insight into our values, and into whose priorities are being represented. So whose security are we taking steps to protect? Should the fact that you walked through a metal detector or elected not to bring a rifle onto the train represent the extent of your responsibility for the safe environment of others? Or do we owe it to the people around us to step in and intervene when people become the victims of threatening behavior? How far are the businesses we patronize responsible for the safety of their customers and their environs? Is there a special TSA machine that can detect assholes, sexual predators, and misogynists?

We are a world preoccupied with the security of our travels. It seems so odd that we would overlook a fundamental requisite for the personal safety of so many.
#SafeTravels, everybody.

Friday, August 2, 2013

This one's for you.

I want to say something important. I have spent the last 24 hours watching so many of my dear friends shatter and fall to pieces in the wake of this loss and I need, so desperately, to reiterate to you the value of your life. The impact of this loss is so severe, and has reached so far. It is staggering, unimaginable, paralyzing. You cannot possibly overstate your own value. The very act of living, of being, of filling a space, of sharing the experiences, tragedies, hilarities, sights, sounds, smells and tastes of the world connects you to the rest of us in ways that you cannot imagine. And when you go, when you tear out those roots and disappear, you cannot conceive of the damage you do, the destruction you wreak, the hideous vacuum that you create. You cannot possibly know the countless hours that the people you leave behind will spend staring into the abyss you left us, the confusion, rage, grief and guilt that will rush in to fill this space you once inhabited. And you cannot, you must not, know that everyone that you have touched, or met, or changed, or known, or caused to smile, will spend one of the most ghastly and desperate moments of their life when they recognize that empty space, when they stare into that place that you will never be again, when they realize that you were real, and you were alive, and we shared this earth, and that you are never, ever coming back. You will leave so many of us to face those minutes of loss and fear, and they will add up. You will inspire countless moments of terror, and of pain, and they will be crippling. You will leave a legacy of hurt and destruction that you cannot even imagine; you will create a loss so intense that it will overwhelm us all. You are necessary. You are loved, and needed. Even if you think you are not. Even if you think you have no worth. Even if I am mad at you, or if we haven't spoken in years, believe me, you are so important. You are a light on the earth, a miracle, a keystone. You are an inspiration, and a co-conspirator, and a friend. You are so, so important.  And you cannot possibly know, you could not have known, because had you had the remotest conception of your worth and your value you could never, never have done this. And so I needed to tell you, all of you, those of you I haven’t seen in decades, and those of you I may have just met, those of you I never will meet. You are precious, you are adored. You have a place, and a role, and there is a need for you as a human on this earth. We are all in this together, and your loss will stab the brutal fingers of anguish into remote places you could never have foreseen. Please, please know that you are valued. Depression lies. It perverts reality and it mutilates truth. The truth is that you are special, remarkable, invaluable, irreplaceable.  The truth is that you are you, and that there is nothing more devastating that you could take from us. You are precious, and you are not alone.

Wednesday, May 1, 2013

Like a bad penny

Damned if I ain't back. This blog took a brief vacation in the interest of actually fulfilling my responsibilities, and then was somehow subsumed by various obligations to causes that further my own ends such as ever completing my doctoral degree or making some money.

Also I got married, but don't be alarmed. This will never be a blog about a wedding. Suffice it to say that there is no limit to the shit that you can spend your money on when you are planning a wedding, and that NO ONE has a sense of humor when it comes to matching the napkins to the floor or finding a plant that people aren't allergic to to staple to a tux jacket that you may or may not recoup a deposit from. Moreover, there is so much useless bullshit that is suddenly a dramatic imperative, like somehow you won't be really married without it.
But I digress. My point is, that somehow, by hook or by crook, I had to get some money. And as an ethicist, I am morally prohibited from hooking, because that is against the law in the state of Washington.
Thankfully, there seem to be an innumerable cadre of jackasses desperate to give me a paltry sum in exchange for a modicum of effort on my part. While I formulate for your edification and entertainment pending posts about genetically modified foods, patenting DNA, water fluoridation and the consumption of neurotoxins, please occupy yourself with the following exchange. Also if you have any money you want to send me start stuffing it into an envelope because SHIT IS REAL IN 2013.
Sent: 4/9/2013 11:41 AM

Subject: Invitation to Contribute to Pain Medicine Board Prep Course

Good afternoon Dr. Emmi (REDACTED);
My name is (REDACTED) and I am the Editorial Program Coordinator for (REDACTED). (REDACTED) specializes in developing and conducting CME-accredited, board preparation courses across a range of medical specialties.

I would like to offer you the opportunity to participate in the process of writing multiple-choice questions for our Pain Medicine board prep course.

This is an opportunity for you not only to improve a rigorous educational product tailored specifically to help other pain medicine doctors prepare and pass their board exams, but also to be compensated for your expertise. We are currently offering $625 for a total of 25 questions ($25 per multiple-choice question).

Please note that we are not asking for you to recall actual board exam questions nor can we accept actual board exam questions; rather we are asking you to compose original multiple-choice questions based on the published exam blueprint. Our goal is to provide the best learning tool we can to help physicians prepare for the actual exam.

We provide specific writing guidelines and examples, explaining how to write questions for this board preparatory course and what standards we expect.

Feel free to contact me directly at (REDACTED). You can learn more about API at (REDACTED)

I look forward to hearing from you soon.



Sent: 4/9/2013 12:06 PM
Subject: RE: Invitation to Contribute to Pain Medicine Board Prep Course

I would be delighted. I agree that given our evolving paradigm of education, it is imperative that we develop more progressive and relevant methods for assessing comprehension. To this end, I have been perfecting a technique of "chronoscopic interrogation (patent pending)," which allows the test taker to envision a holistic context, further complimented by each subsequent query.  Please see my sample questions below.

1) Just what the hell are YOU looking at?

2) Do you want a knuckle sandwich?

3) Does this hurt?

4) What's your problem, pal?


Thank you for your interest in our progressive method of pain management.  The large body of evidence supporting experiential learning suggests that in order to effectively manage pain, the pain must first exist.  That should learn them real good. Please feel free to contact me for further input.
My very best,
(the "Doctor" is silent.)
I am still waiting for my check, but I feel assured that a highly professional institution such as the one above that doesn't even need to confirm that I am not an anesthesiologist will have no problem delivering the goods.
Thanks for coming back to me, babies, you know I love you dearly. This will almost assuredly never happen again.*
*this pretty much guarantees that this will happen again tomorrow. Tough shit. I don't do this for my health, you know.



Tuesday, April 3, 2012

Comparatively, someone's usually an asshole. (It's probably me.)

Having a blog is so great in theory but really when your life is defined by the demands of graduate school and the dubious prospect of meals you can prepare in three minutes, it becomes more and more difficult to generate content without actually going outside and getting arrested. Not that I have ruled out that contingency, by the way. 
In lieu of anything interesting I have done recently, and as I prepare for an actual adventure in the near future (Look out, Tokyo!!), here is some small change from our recent trip to Phoenix. 

Actual Quotes from Actual People in Arizona: 

"I popped in there the other day, and you know, that was the dinkiest gun store I ever been to. I mean, talk about a poor selection, I seen better than that at some of them estate sales." 

"Did you hear about all the problems they had with bears getting onto the golf course? My game was bad enough to begin with, now I have to worry about bears?!"

"That there's the black guy's house." 

"Look at all those emergency lights.  What do you want to bet there's a golf cart underneath all that."

"you can really tell the age of a community when you got 35 thousand places that do dental work and about three million urologists."

"look at that bastard all sitting out there in his wheelchair with a margarita."

Additionally, I became apoplectic with fury on the flight home and had to go pace the length of the airplane bathroom until I calmed down. By which I mean I got so dizzy from spinning in a circle that I forgot how pissed off I was.
Mike bet me I wouldn't write a complaint letter. Since I am too mature to ever turn down a dare, here is the email I sent to customer service. 

Dear Sir or Madam,
I have preferentially flown with Delta for over ten years now. However, I have cause for complaint with an amenity of yours which makes me significantly less likely to fly with you in future.
Your "interactive touch screens" are appalling. Many of them refuse to shut off properly, persistently bombarding one with incessant advertisements, flickering images, and the imbecilic, mutant rictus of your corporate spokeswoman. The screens are bleary and smeared, suggesting the accretion of months of mucus coated particulates from the mouth-breathing, meat-mittened, sebaceous cretins jabbing at the unresponsive monitor in fruitless attempts to repeatedly view the unmitigated crassness of the preview for “American Pie 5.”
However, the potentially infectious and demonstrably grimy abuse of this feature is not the focus of my complaint. I write to address a more specific canker: the monstrosity of your in-flight trivia game. Never mind that the content of the questions is so abstruse as to be preposterous - Do you realize that 96 percent of the American population thinks that the passerine is a type of fruit? – but given the recondite nature of these so called “trivia,” one might safely assume that those responsible for the creation and presentation of the game to have at very least a ninth grade equivalent proficiency in spelling and grammar. To my dismay, this assumption was belied in the most galling manner.
It would behoove those responsible for the production of this atrocity to address themselves to the rudimentary foundations of the English language; most notably, the appropriate employment of the much abused apostrophe. Contrary to popular opinion, the placement of an apostrophe in a given word does NOT signify the advent of the letter “s,” nor does it by default indicate a possessive plural. An apostrophe placed in the word “It’s” connotes the contraction of “It is,” while that in  “Who’s” is representative of the redacted “I” in “Who is,” and not, as your inane, pestilent cesspit of arcane knowledge insinuates, the possessive “whose.”
Please attend to this matter immediately, as I will not hesitate to put in train a petition to the other four insufferable pedants on this planet who might be roused into righteous indignation by this type of bagatelle.

I expect a complimentary jet any day. Now if you'll excuse me, I need to get back to watching videos of pets falling off things and crying about my thesis. 

Tuesday, February 14, 2012

I reviewed My Cat.

Someone told me that if I want more directed traffic on this blog, and not just a bunch of lunatics searching for insane things like "enema toilet" (this is actually a thing that a person searched for and came to this blog. While I can sort of appreciate the convenience factor I don't think I can wholeheartedly endorse this product.) I should "engage more with the internet."

The internet horrifies me and I can barely use a toaster.
But I started small. I started by talking about the weather.
I liked some things on facebook.
Then I drank too much and upvoted everyone on Reddit, which is probably an internet faux pas but how the hell would I know since they didn't actually make me sign a waiver.

Then I took the plunge and REVIEWED MY CAT.

and I got retweeted, which I think is like getting a really unimpressive award but I got unreasonably excited about it because the internet is like a foreign country in which I can only recognize the native language for "hello" and "fuck you."

In any event.

This seems like as good a time as any to admit that you can now follow me on twitter.

I'm sorry.

Thursday, January 19, 2012

Unavoidably Unsafe: vaccine truths in the information age

Well, it’s 2012 and I’ve made some resolutions. I like to make a lot of them every year, because statistically I can probably manage to stick to one or two just by virtue of having about fifty. Some of them are pretty easy, like “Don’t drink drain cleaner,” and “try and avoid contracting a heritable disorder,” but some of them, like “Don’t use hand sanitizer to get drunk in prison” are tougher. Some things are just beyond my control.

One thing that I have actually committed to doing is to write more about issues that matter to me. It’s super easy for me to craft a post for the sole purpose of referring to Daniel Quinn as a total asshole, but not so easy for me to deliberately confront my own defensible truths. And so in my first post this year, I want to write about something that I think is really important to a lot of people, and that’s a frank discussion of the doctrine of fear surrounding vaccinations.
I have been flippantly censorious of the vaccine phobia more than once on this blog, and I unequivocally stand by my position that exposure to Jenny McCarthy should result in a quarantine. I will, admit, however, that statements like that don’t really serve to educate or conciliate people who don’t already agree with me, and I’m not sure that it’s not an irresponsible application of my education in health sciences to alienate people who have legitimate curiosities about the dangers of vaccines.

Historically, the implementation of all public health interventions has been characterized by a conflict between personal autonomy and public benefit. This poses a formidable dilemma. The ethical execution of public health should always take into account the fact that implementing public health programs creates a palpable tension between individual autonomy and perceived population benefit. While it is, of course, requisite that there always be an explicit respect for persons inherent in every public health action, there are instances in which the overarching principle of beneficence takes precedent. Those instances must be carefully analyzed and objectively evaluated, and they are rare and far between. Newborn screening programs, childhood vaccinations and water fluoridation are three of relatively few such programs ever implemented in the United States. The conflict is not one that policy makers underrate; it’s difficult to minimize the impact of what might be characterized as a transgression on personal freedoms in a society as committed to individual liberty as ours.
This is especially difficult when policy dictates that we impose a measure in the name of public health that is perceived as dangerous, and potentially harmful. Vaccinating children is such a measure, and the controversy generated by state laws mandating these vaccinations has been prodigious.
It is really easy for those of us in public health to dismiss dissenters as lunatics and morons. It is really, really easy to wax lyrical about the fatuity of this movement, to make fun of the maniacs who commit violations of federal laws to expose their children to infected candy mailed to them by a stranger from the internet, OH MY GOD. 
But it is ultimately not very helpful.

It is irresponsible and harmful to dismiss this population as imbecilic or insane. I realize that it’s simpler, and I’ve been guilty of it myself, but in many ways that behavior reduces you to the practice of blaming the victim. The central tenet of public health is not that we show respect only for the people who agree with us. Public health requires a necessary element of education, because you are not dealing with a horde of scientific practitioners, you are dealing with the public. IT SAYS SO RIGHT IN THE FUCKING NAME. Public health. And public opinion matters, especially in a case like this.

So in my opinion, it is far more efficacious to acknowledge that these fears exist, and that the potential impact of these fears on the overall health of our population is significant. And that, whether or not we believe wholeheartedly that these fears are ignorant, or wrongheaded, or pernicious, we do not fulfill our duty to one another by deriding those beliefs. So here are some facts.

Vaccines work by providing the body with an ersatz version of the disease in question, and allowing the body an opportunity to mount a response to the fascimile, without exposing the individual to the whole package. Diseases are neutralized for vaccines in different ways. Often, the infectious agent is killed by heat or other chemicals. sometimes, the virus' ability to reproduce is destroyed, meaning that the disease cannot mulitply in the body. For some diseases, like hepatitus, it is enough to simply expose the immune system to an associated protein. Once a virus has been killed or neutralized, it cannot hurt you. The illness that people feel after receiving a vaccine is not the virus contained in the vaccine, it is your immune system responding to a foreign agent, memorizing it, and mounting a response designed to remove it. Once your immune system has recognized something as harmful, it can be destroyed. And given another exposure, your body will simply annihilate the intruder without the necessity of a full scale immune response. This is why people only get the chicken pox once - your body won't be fooled twice by the same trick. Colds and influenzas are slightly different, since those viruses are always changing and adapting. This is why some people get a flu shot every year.

The truth is that vaccines are not always 100% safe. They contain some preservatives that look and sound alarming. They occasionally precipitate an immune system response that can be unpleasant. Other safety concerns have revolved around mercury and Thimerosal, which is a compound containing organomercury, historically used as a preservative in vaccines and other medications. Over the course of the last decade, safety concerns about the use of Thimerosal (also known as Merthioloate, the trade name of the compound developed by Eli Lilly) have prompted the FDA to phase out its use from vaccines given to children under six. That means that the Measles, Mumps and Rubella vaccine, traditionally given at 18 months, does NOT contain Thimerosal.
It is worth noting that all of the multiple trails testing the safety and efficacy of Thimerosal have suggested that the compound is safe for the controlled uses to which it is put. However, public opinion and preference has guided the evolution of policy on this issue; and the development of more acceptable compounds has made the substitution much easier.

One exceedingly harmful myth about vaccines is that the government requires them simply because the government is in business with big pharma. THAT IS FALSE.

Vaccines themselves reside in a nebulous legal category known as "Unavoidably Unsafe." This is a designation given to drugs that are deemed necessary for population health, but which cannot be designed to be entirely innocuous. This label means that there is a certain amount of risk inherent in the treatment, but that the benefits outweigh the harms so significantly that there can be no question about the propriety of administering it.
If a company were to be held responsible for every adverse side effect resulting from a drug, there would be an enormous economic disincentive to making that drug. This is why safety trials are necessary. If, however, the product is considered necessary, the companies that create these products are allowed a certain amount of indemnity from litigation, in order to assure that access to these necessary treatments is retained.
Products  must meet very, very specific criteria in order to be considered "Unavoidably Unsafe." The product must be produced to the standard specifications, meaning that there must be no error or negligence in the actual production of the product that caused the damage. If a company were to make a mistake in a batch of vaccines, for instance, and accidentally add a bunch of rat poison, the product would not be considered "Unavoidably Unsafe," it would be considered "Shitty." Secondly, the marketers of the product must be transparent about the potential known risks. The product must, as discussed above, have a clinical utility that greatly overrides the potential for harm, and there must be no other alternative to the product available.

As it stands, we don't have a better alternative for vaccines. They can sometimes cause our immune systems distress. Care providers are honest about those potentials, and vaccines have proven to be so advantageous and beneficial that those risks have been deemed acceptable. And all of this would be ok, if it weren't for our 21st century witch hunt for the causes of Autism.

An additional truth is that the vaccine schedule is, in fact, kind of arbitrary. Vaccines are scheduled at 18 months because they will conform to the changes in a child's immune system as they acquire their own resistance, and so they will coincide with established wellness checkups. That is convenient, and in the consumer driven medical market that we have created for health care, convenience is king. It is also true that 18 months is the time that many symptoms of disorders on the autism spectrum become apparent. It’s understandable that this connection might be where we start to look for a causal relationship.

What it is imperative to remember is that correlation is not causation. A 1998 study published in the British Medical Journal, The Lancet, claimed to have demonstrated a causal link between vaccinations and the onset of traditional symptomology pathognomonic of autism. This study terrified people, and caused a widespread panic. Consequentially, many people refused to vaccinate their children, and the findings were widely publicized by the media.  Over the subsequent decade, follow-up studies failed to replicate the results, all of the co-investigators of the study dissociated themselves from the paper, and in 2010, the Lancet itself withdrew the publication. What this means is that the information and the associations supported by the data collected in the study have proven to be spurious. As it turned out, the lead investigator was found to have fabricated those data, and was forced to acknowledge the fraud in ignominy. The twist here is that this retraction was not as widely publicized as were the initial study findings. The NIH and the WHO did not embark on an aggressive media campaign, trusting that every mom in the world had nothing better to do than refresh the lancet website daily researching ethics violations. Even I only do that when I’ve been drinking cooking wine and thinking bitter thoughts about Anthony Bourdain.
So what we’re left with is a significant proportion of the population that have been grievously misinformed by a primary source, which was subsequently interpreted and disseminated by innumerable other sources and inadequately refuted by organizations that should have made it a top priority. By then it was a little late; the damage was widespread, and the consequences are becoming apparent.

The concept of population health is in a way self-sustaining, in that we rely heavily on acquired or achieved immunity in others to protect ourselves. We call this “herd immunity,” and we base our assumption on the principle that diseases rely on susceptibility in their target organisms to spread. reducing the overall susceptibility in a population provides less opportunities for infection, thereby reducing the rate of incidence. When a large cadre of people fail to acquire immunity through vaccination, an infected agent’s ability to spread is greatly increased. Already in the United States we are seeing the consequences of the reluctance to vaccinate, in resurgences of diseases we had previously suppressed, such as whooping cough, and Rubella.
the vast majority of opposition to vaccinations is predicated on information that was fraudulently derived, and irresponsibly disseminated. I think that frustration with this misinformation is driving a large proportion of the intolerance that many medical professionals are demonstrating when people express their concerns, but I don't feel that that frustration gets us anywhere.
Our society places a high value on the principle of autonomy. And if you are an advocate of autonomy, it's important to realize that the option of choice should be exercised responsibly, and on the basis of the best information available.  Fear and tenuous supposition are poor substitutes for ratiocination and primary source material.
So let's be excellent to one another. And don't eat shit you bought on ebay. Jesus Christ, guys.

Friday, October 21, 2011

Mutation, Misinformation and the Marvelous Mütter Museum: Not a Children’s book by Emmi

It is one of my absolute favorite times of year. I love the (stipulation: rare) stunningly clear and distinctly scented autumn days, I love the sweaters, I love the flavors of fall – the pumpkin, the sage, the maple syrup, the late blackberries. I love the way, even in the miserable, soggy, grim expanse of the pacific northwest, that subtle blush of color spreads over the leaves until all the trees blaze out in a defiance of crimson.
And I love the fall fashions. I get excited every year to see what new trends emerge. This year, there doesn’t seem to be much novelty in vogue, which has been really, really disappointing. Much like last year, we are still seeing a preponderant focus on ADD, ADHD, Asperger's, and bitching about the flu shot.
Oh heavens, I’m sorry. Did you think I was about to talk about clothing? If you want my sartorial critiques you are just going to have to wait until spring, when I’m good and donked up on vino verde and someone gives the Olsen twins another slab of stock in Walmart. Until then, I’m going to stick to sarcasm directed towards issues more directly in my wheelhouse, though admittedly those issues are pretty much confined to “bottles of wine that cost less than 10$.” But it’s my favorite season, google keeps sending maniacs to this blog, some people just had shoulder surgery, and anyway I’m hoping to post a little more frequently this term, as It has become far more imperative that I avoid any actual work. There’s also the small matter of needing to step up my game after I accidently promised to marry everyone I meet on the internet.  I’m inspired!
So God damn, could we just move on to something innovative in our disease crazes? For years, we have been over-diagnosing and carping about the same old shit. Remember when suddenly everyone had depression? And now everyone has ADD? For god’s sake, everyone had Attention Deficit Disorder when I was a kid, and it’s been completely played out for years. For awhile, I really thought that the grand obsession with the Autism spectrum was going to help guide our focus in a new and truly avant-garde direction. But, no. Alas. I don’t exactly know who decides these things, but please just get a grip. It is way past time to move on. These guys are sticking like denim when they should have been jeggings. Let’s be real.
Every year holds the promise of a new arena of pathology, and every year I’m held back by a redundant deluge of the several million examples of why we should probably declare Jenny McCarthy’s asinine twitter feed a public health emergency. This year, I was so sure that things were going to be different. Firstly, we sequenced the BLACK PLAGUE. THE BLACK FUCKING PLAGUE, Y’ALL. And then we found out that the black plague AINT SHIT! How Badass is that?! Like, if the black plague were to come back, our immune systems wouldn’t even give a fuck! Our immune systems would give the black plague the kind of scornful once over that gets directed towards a fat girl who wore the same dress as you to a party. “Oh,” our immune systems would say. “I didn’t know you were coming.” As an aside, our immune systems would turn to our nervous system and whisper something about how they just let anyone in, these days. Daaaaaaaamn.
Secondly, popular culture has given a big boost to those of us in the health services by making epidemiology really, really sexy.

Remember how lame Dustin Hoffman was in Outbreak? 2011 won’t stand for that! The bathrooms in movie theaters after Contagion lets out are filled with people washing their hands more thoroughly and self consciously than ever before.
I realize that it’s really difficult to establish a cultural trend of conditions that are at baseline binary – I mean, you either have tuberculosis or you don’t. But there are so, so, so many disorders that fall somewhere on a diagnostic spectrum; couldn’t we just give one or two of those a chance to get crammed all the hell the way down the throats of people until we’re so goddamn sick of them we could just die? Like Trichotillomania, or Histrionic personality disorder, or Anemia? Obsessive Compulsive Disorder looked to be making a comeback, but much like overalls, that movement fizzled out in a hiss of Jack Nicholson.  I think we’re doing a massive disservice to a huge component of the population by failing to acknowledge that pestilence, plague, and the vast and colorful spectrum of viral and bacterial infections are relevant and often integral parts of many lives. Maybe we could start a movement encouraging increased sensitivity? Who exactly decided that whole populations are suffering from a disadvantage as opposed to an alternative lifestyle? I’ll be the first to acknowledge that I don’t always remember to refer to some individuals as “differently-eased.”
I know that some of you will be skeptical. “What’s next?” You’ll ask. I’ll probably ignore you. Considering that the slippery slope argument inevitably ends in the mass extinction of a vulnerable population or sex with dogs, I try to use it sparingly if at all. I can only take so much.
On that note, Let’s talk about pathology as a pastime.
The Mütter museum in Philadelphia is a warped wonderland of deformity and bizarre affliction.
A monument to morbidity, the museum is in fact beautiful, gleaming mahogany and burnished wood cases housing row upon row of grinning, alarmingly imperfect skulls behind spotless glass.
In a concession to modern sensibilities, there is a half assed exhibit at the very beginning of the museum dedicated to medical forensics, civil war wounds, and forensic anthropology.
one of these was a lady.
It doesn’t take long to get to the good stuff, though; Some broad that turned into soap and an entire case of surprising things that grew out of various sites generally considered unpopular or insalubrious for things to grow!
like a forehead.
The museum itself is a part of the Philadelphia College of Physicians, which, founded in 1787 boasts the oldest doctors in America. (Some details fuzzy.) The museum metastasized from a collection of curiosities donated by Dr. Thomas Mütter in 1858, and quickly became a repository for all the screwed up things people secretly want to look at but need some thinly veiled educational veneer as an excuse. 

the sign reads: “I have been digging this shit out of urethras for 35 FUCKING YEARS and putting it in jars. You can judge but please remember you paid to look at this.”

  That sign says, “I kept this monster hand in a jar so that next century, all you little bitches who can buy hand sanitizer in the express line at Old Navy and know how to defecate remotely can wrap your sterile little minds around what Gangrene looked like.”

One of my favorite exhibits was this exquisitely articulated skeleton. The bones are twisted and feathery, the joints eroded by strain and friction. As a piece of art, it’s breathtaking. As a monument to the freakish potential for human suffering, it’s heartbreaking.
This exhibit below was way more fun, because it is the direct result of the fascinating and limitless extent of human imbecility.
There are 32 drawers in this cabinet, and each one of them is filled completely with the staggering array of fatuous things that people have somehow choked to death on.  All the usual suspects, like buttons, small bones, marbles, sanctimony and excessive cologne are all represented, but some of this shit is insane. Why would you put fishing lures in your mouth? Why? WHY????! I can only conclude that there are numerous people who have just got the concept of fishing completely ass backwards in the most pathetic and tragic way possible.
One of the specialties of the museum is abnormal births, and there is an entire wall dedicated to portraits and biographies of Siamese twins, jars of conjoined fetuses, and in one central isolated case, the embalmed body of conjoined brothers who lived into old age, acquiring separate farms, and wives, and lives that they took turns living weekly.
The museum may seem grotesque, exploitative, morbid, deranged. But the subjects are preserved lovingly, displayed with respect and deference, and painstakingly cared for.
While it’s true that I was fascinated by some, and repelled by others, and while it’s clear that the point of the museum is to cater to that slightly unhinged, gruesome obsession we have cultivated with the alien and the dead, there’s something to be said for how humbling it feels to stand in front of the skeleton of a ten foot tall woman, and wonder what your life would be like if you were defined by an aberration so extreme you could never hope for an interaction that was not somehow colored by it.
And there’s something to be said for the kind of miraculous transformation that can bring us face to face with the freaks and the feared, the sideshow mutants and the tragic remains of lives lived in pain, and somehow endow the encounter with dignity and intimacy, and leave us with the suspicion that just beyond some numinous boundary, the things we deny are reverently illuminated and monstrously sacred with the strangest beauty.

Thursday, October 6, 2011

Chinese Medicine

It’s been a long few months. As much as I am enjoying graduate school, I have to admit that being obliged to prioritize all my activities has really forced me to acknowledge just how much I enjoy drinking. Boy oh Boy. Then again, people talk a lot about the benefits of recognizing and being mindful of your coping mechanisms, and since I don’t have health insurance I’m pretty positive that even if I really stepped it up and starting drinking at ten in the morning it would still be cheaper than therapy. Probably. Even assuming I only have about ten or fifteen therapy sessions a week, I would still come out on top. And this way, I can have therapy any time. WHO COULD JUDGE ME FOR THAT?!
I currently require more medicinal alcohol than usual, given the time of year and the uproarious run of luck I’ve been having lately. Some people get really excited for sweater weather. I get really apprehensive about spider weather. The Pacific Northwest is home to some incredible fauna, such as conifers, seasonal depression, and arachnids. Given the concatenation of various factors of my life, such as the fact that my house is a moribund wreck on par with Miss Havisham, the fact that there is obviously a curse on me, and the clemency of breeding conditions for ghastly pestiferous eight legged fiends, this has been a banner year for horrifying shit occupying my house. Even allowing that every year yields a prodigious crop of things that I completely fucking hate, this year has been particularly fruitful thanks to the nest of bragilions of what appear to be actual BLACK WIDOW SPIDERS LIVING IN MY DRYER. Although this is statistically unlikely, it is also not improbable given that my life is generally punctuated by the type of bad luck that is both contingently remote and generally inexplicable.
The consequences of this pyrrhic discovery are diverse. I live in fear, I am applying for a permit to carry a bazooka, and laundry is hella old school.  Until an exterminator comes, our house is covered in layers of undergarments I washed in the bathroom sink. As usual, the environment around me is undergoing the inexorable transformation into that of a whorehouse.
As a more relevant repercussion, however, I have become excruciatingly aware of the inadequacy of my health insurance. Granted, a perfect plan for me would cover burns, inadvertent poisonings, spider bites, ethanol IVs, ancient curses, things I accidentally swallowed, motorcycle crashes and dysentery, which I hear from my HR representative is unlikely. But health care, and what constitutes adequate insurance for health care, are hot topics in the current landscape of U.S. legislation.
The general underlying premise of health insurance in various nations is predicated on what, in terms of U.S. constitutional law, is considered a right. Certain nations consider health insurance to be an unalienable right, whereas some philosophies regard it as a privilege. Regardless of your own personal opinions on the subject, it’s pretty clear that these diverse ideologies give rise to equally diverse systems of care.
Chinese medicine is more of a holistic process than the mostly reactive, specialized event type of care common in the US. Some aspects of Chinese medicine are completely accessible, intelligible, and evidently effective. Some are alarming, confusing, and inexplicable. And some processes are simply ineffable. A lot of the obstacles Western individuals encounter when attempting to parse Chinese medicine are direct results of ideological conflicts between Eastern and Western philosophies.
Health care in the United States is primarily evidence based, responsive, sterile, and specific. We manifest a constellation of symptoms, we remark those symptoms, we submit them to an accredited expert, and that expert in turn analyzes those symptoms and pronounces a diagnosis, which then informs a prescribed course of treatment predominantly contingent on the disease rather than the individual. Western medicine applies a highly specified and specialized approach to illness; conditions belong to specific parts of the individual’s body, and have distinct definitions and parameters.
The Chinese approach to medicine is entirely different; the individual is viewed as a system, each aspect is interrelated and dependent on the others.  We as westerners have some difficulty envisioning the concept of a life force, a motive, fluid, dynamic and animate power within the body and the mind that flows both perceptibly and inexorably.
Also, putting a snake in a bottle and covering it with booze is not necessarily consonant with my idea of tylenol.
My field being medical ethics, and having a personal investment in the scientific method, there was pretty much no way I could visit a country with such a markedly different epistemology without participating in some hands on research. The following  activities are things we engaged in in the interest of exploring alternative ideologies.
(Note: As the Principle Investigator, I was able to outsource some of the more tedious data collection, and focus on diligently documenting the procedures and adhering to the protocol. Being a PI means that you don’t have to do any boring shit like math or work. You get a graduate student to do that kind of BS.)
This treatment requires that fire is used to suck the air out of a glass globe, which is then immediately affixed to your skin by way of advanced super heated vacuum technology. Ever cleaning the globe is unacceptable.
EEEEEEEEEK. Tedious Data Collection like being IMMOLATED.
Bamboo cups are added to make you look less like a pokemon. The difference between the two vessels, and the rationale for the disparate application, was not explained to me in a way that I could comprehend. This could be because it doesn’t make any sense, or because my Chinese is so overwhelmingly Bu Hao.
The final product, is, however, inspiring.
It’s a miracle! He’s cured!
It is, of course, possible to visit modern hospitals in China. The Matilda hospital in Hong Kong is considered one of the most superlative and progressive research and treatment facilities in the world. However, in addition to massage, cupping and liquor distilled from the types of organisms generally associated with nightmares (perhaps they would like a tour of my basement?), ancient Chinese medicine is a discipline practiced widely and successfully.
My experience with Chinese medicine had heretofore been exposure to repellent substances that are alleged to improve virility. There is traboccant evidence to prove that the worse a thing is, the better it will be for your manhood. Rat juice? Horse Anus? Essence of Cloaca? These are not Ozzy Osbourne solo projects. These are treatments.  It might also be germane to note here that every other experience I have had with Chinese medicine has been the procedure where a person repeatedly strikes your wrist with their eyes closed and then tells you that you’re fat. This should be experienced annually.
So imagine my excitement when our friend Shao Shao offered us the opportunity to consult with a traditional Chinese Medical Doctor in his home clinic. I don’t know what you picture when you hear the term “home clinic” (For me, it’s reminiscent of the bathroom cut scenes in Silent Hill, but you may have had a better childhood), but the reality in this case comprehended a single room with a corroded floor, flyblown mirror, and a  peeling decal of a long washed up Chinese pop star on the wall. At least it wasn’t a home surgical suite.
The room was about 20 square feet, and was crowded and damp. In addition to myself, my brother, Shao Shao and the doctor, the room contained a camp bed in déshabillé, a rusted rotary fan, two ancient computers, and several posters of the human body of the type usually seen on the wall at budget massage parlors. (as an aside, unlike Vietnam, massage parlors in China are not generally used as euphemistic fronts for whorehouses. Those are hair salons, as Chinese humor is geared towards the growing body of 12 year olds that think a double entendre involving the word “head” is hilarious.) Drying lines of faded clothes and greying underwear were roped across the ceiling.
The doctor himself was wearing an outfit that presumably conformed to the standard professional uniform. A hastily donned frayed white shirt, paired with worn professional grade underpants. “BAD BOY!” proclaim the ragged boxers. “USA!” 
After the introductions, the exam began. Fred admitted to feeling tired and stressed out. The doctor asked about his diet, his exercise, his love life. He prodded Fred in various places, and listened to his chest.

Towards the end of the exam, the doctor repeatedly tapped Fred’s wrist and then informed him that he was fat. Thank God, because I was beginning to feel a little self conscious and uncomfortable. “Should I say something?” I thought. “I’m certain this man is really breaching the standard of care by omitting this procedure.” We were looking at a serious malpractice suit here. What a relief!
Ultimately, the doctor gave Fred a plastic pouch of his personal formula of all purpose panacea, which he kept in a grungy plastic bag underneath his camp bed.
The storage instructions in Chinese translate roughly to: “Keep in a gross dark place. Film with grime. Refrigerate after opening.”
He also wrote Fred a prescription for another demulcent, which could be filled at any pharmacy.
The efficacy of this treatment is currently under evaluation.
In many ways, I enjoyed my experiences with Medical treatment in China far more than I have in the states. I find a lot of comfort in massage. I feel like western medicine has a lot to learn from acupuncturists. I firmly believe that the US could benefit from the Chinese practice of providing pedicures with 90 minute foot rubs for less than twenty dollars. But more than anything, I really enjoyed the novelty of being treated as more than the sum of my parts.
Although my experiences with the Gynecologist were really unsettling.

Wednesday, April 27, 2011

A Mystery of the Orient: The Curious Case of the Caliginous Cabbie

Inner Mongolia is barren as hell. Spindly cows stagger across the dehydrated plains. Mesas loom grimly above a parched landscape, acarpous and scorched. Rugged mosquitoes with slouchy porkpies and rank cigars roughly assault your sunburned skin. Water costs more than beer.
    We trekked across the flatlands to join an academic conference in Xilinhot attended by several of Fred's classmates. Xilinhot is famous for giving a shit about Genghis Khan, by which I mean that Xilinhot is pretty much the cultural equivalent of the bar attached to a Super 8 motel somewhere in North Dakota on a Tuesday night. They have a cultural history museum, the top floor of which is dedicated to paper mache reproductions of the Tyrannosaurus Rex. They have a national gynecology hospital, flamboyant, evocative and nauseating in festive pinks and purples. What they do not have is a hotel willing to board foreigners or a restaurant that doesn't evoke the subconscious self loathing of a first date at a bowling alley.
    Fred and I dragged our bags in and out of several reeking taxis, trudging from hotel to hotel. One woman screamed when she saw us. Another one called the police.
This turned out to be awesome, since the police decided it was part of their civic duty to find us a hotel. They placed us in the back of their police car and drove us down the seediest, most pathetic street that ever wended its useless way to a hole that would rent a room to white people.
IMG_6111 civil servants.

    The hotel was hidden behind a high facade, festooned with topless men lounging gracelessly on the grimy bricks, T shirts tied around their slick foreheads, beer bottles sweating rivulets in the merciless heat. Women dangled ugly babies and stared vacantly as the police cruiser scraped its way up the uneven drive. At night, a motley and swashbuckling pride of indolent taxi drivers lurked around the hood of an idling Buick, smoking harsh cigarettes and squinting into the broken street.
    One of the benefits of finding yourself in an area with limited tourist appeal is that there are fewer aggressive individuals with insinuating smiles that are willing to take you to see something for a "cheap price." One of the drawbacks is that there are still plenty of people willing to take you to see nothing for a whole lot.
    So when a jovial, portly, middle aged cab driver offered to give us a tour of the terrain surrounding the city, including the places his parents took him as a child, we were mildly skeptical. "We don't get many foreign visitors here!" He exclaimed, rubbing his shiny forehead with an honest to god handkerchief. "I think it is our duty as citizens to show our visitors our country." Fred was for it because inner Mongolia is as boring as watching a cow starve. I agreed because my intuition is more likely to endorse an individual if he looks like Mr. Pickwick, regardless of ethnicity. D. agreed to come back for us after lunch, and told us he would charge us about 15 US dollars.
    The first leg of the drive was beautiful, in a barren sort of way. D drove along the back roads so we could watch lanky, ochre colored boys drive spindly, wild horses across the plains.
The parched ground was cracked, and nearly smoking in the noon sun. D. drove slowly, stopping every time I pointed my camera out the window. With the day at its hottest, we pulled the cab into an uneven gravel lot overlooking a wide swath of grassland. We ducked under the blistering arm of a wrought iron gate and hiked up the asphalt path until it ended. The plane was endless, and the rocky outcrops broke the smooth face irregularly, providing slivers of inadequate shade, jutting incongruously and impotently out of the landscape. Below us, blinding in the direct light of the summer sun, stretched the reservoir, the surface glassy and brilliant, crystalline and inviting.
D. led us down a rocky path to the edge of the water, until the stones gave way to a thick, silky mud that coated our feet and left silicate grit between our toes. The water was extraordinary - cool and still, with silvery fish appearing and disappearing rapidly around our ankles. D. waded in up to his waist, and grinned at us. "I never learned to swim," he explained sheepishly. "This is the only water around."
    Climbing back onto the rocky shore, we were greeted by a horde of obnoxious teenagers with cell phone cameras taking our picture. "Lao Wai!" They informed each other, pointing. "Lao Wai!" We affirmed. It was like first contact without the spaceship. I encourage you to go to China with a horde of other white people, and simply repeat everything that people say while they take your picture. If you really want to have some fun,
"dai4 wo3 qu4 kan4 ni3de ling2dao3"
means "Take me to your leader," and I suggest that you throw that in once or twice, just to up the ante a little. Trust me. It will be hilarious.
    Tourism in China is essentially a carnival of shit that is ridiculously old, where you are hustled from one busted thing to the next and people attempt to sell you absurdly overpriced shirts that depict the busted thing you just saw. For years, tourists have gone to China and paid money to look at old busted shit, which is why, when you go to China, people are really enthusiastic about charging you money to see shit that is old and busted. China is really capitalizing on the two pronged theory that 1) things that are "Ancient and Beautiful" are attractive to populations who continually recycle styles from 20 years ago like there is ANY amount of time that might make stirrup pants acceptable again, and 2) that those same populations with the fashion memories of goldfish are by extension unable to distinguish between a pile of rubble from a defunct noodle stand and some palatial ruins from the Ming dynasty. And who can blame them. We are the assholes acting like jeggings are reasonable. Just be thankful that the T-shirt you bought says you saw the great wall, even if it was "Ping’s discount hovel of pajamas." You know in your heart that it doesn't matter to you.
a tribute to a nobler age.   
Acting on the principle that the central tenet of Chinese tourism is "have built it several thousand years ago and they will come," China designs much of their new construction to look like old construction. Our guide led us back to the car, now nearly molten in the heat of the late afternoon, and suggested that he drive us a little out of our way to see the main attraction in the area: a fifteen foot tall replica of Genghis khan's head, molded in plastic and finished to look like ancient stone work; set imposingly on a hill above the largest highway in Xilinhot.
    We hesitated. We were in the middle of nowhere, with little money, in sandals and swimsuits, with no other viable mode of transport, no one to call, and no reasonable alternatives. We looked at each other. We shrugged. We agreed reluctantly, and got in the car. We pulled out of the gravel lot, and rejoined the long dark highway snaking across the grasslands. five or ten minutes passed before we again pulled off the highway. D. shut off the engine. "Just a moment," he said to us.

    If you are now, like we were then, reading this post waiting for the moment that our seemingly philanthropic guide dropped his mask and stood revealed to us in his true colors, you need to read no further. It was at this juncture that this man's character was exposed in all of its nakedness, burning like a brand in the vast expanse of the dry plains. He left the driver's seat, and moved around to the truck of the car. As soon as he was out of the car, I turned to Fred. "What is going on?!" I asked. We had no idea. Was this the moment he would demand additional payment for his unsolicited tour? Were we going to have to battle it out along the side of a desolate highway in the middle of god knows where in inappropriate walking shoes and damp clothing? Did he realize how threatening the eternal, unbroken plains appeared in the context of our potential disagreement? Would he abandon us? Rob us? Sell us? Would the bland, calcified fields surrounding us soon house the drying HUSKS OF OUR DESICCATED CORPSES? WOULD I BE MUMMIFIED IN FRIGGING MONGOLIA OVER A FIFTEEN DOLLAR TRIP TO VIEW AN ENORMOUS PLASTIC REPRODUCTION OF GHENGIS KHAN'S FAKE HEAD?
    We waited anxiously, listening to the thumps and rustles coming from behind us as D. rummaged through the trunk of the cab. For shovels? Shackles? Firearms? Worse?
    The sun was getting lower as D. opened the door and clambered back into the driver's seat, clutching a large sack. His ruddy face was filmed with sweat, and creased into a habitual congenial grin. Under the circumstances, his good natured smile seemed sinister, lochetic, foreboding. Nodding briefly and apologetically to me, he turned to Fred and spoke rapidly in Chinese.
    Beaming, he produced two large water bottles from the bag, slick with glistening condensation, kept cold in a cooler in the trunk. Fred translated. "He thought we might be hungry, and he saw on a television special once that white people like to eat bread, so he went to the store. He wasn't sure what kind of bread white people like, though, so he bought us a couple kinds. He said they were out of coca cola, and they only had pepsi, so he got us water. He hopes that's ok. He knows Americans really like coca cola."
    Although in a sense anti-climactic, the soft yellow loaf filled with dates and jam was delicious, the water welcome to throats as parched as the steppe. Our guide drove faster through the growing twilight, explaining that if we could mount the next hill quickly, we could watch the sun set over the bright silver rivers leading into the reservoir.
    At the summit, we pulled the cab off into the bushes and turned to watch the deepening  crimson rays glance brilliantly from the surface of the winding tributaries, and transform the dales into pools of gold and shadow.  In the last dying light, a collapsing cottage caught the final beams and blazed into an unexpected beauty, radiant in its liquefaction, in the syrupy golden of the thickening dusk. Never had some old busted shit seemed so compelling in its desuetude; the steppe looked so homogenous in the broad day, but the growing penumbra highlighted the hills and dips. The light on the uneven plain fell in viscous chunks, collecting in dales and running slowly down the hillsides.

    Then we turned our steps towards the head of Genghis Khan.
    As it turns out, the head is better positioned to view from a distance than it is placed for tenable approach. In our plastic sandals, we climbed over barbed wire fences and the ruins of old cattle pens. Nettles brushed our legs, huge crickets exploded from the brush up into our faces, whirring and clicking like mechanized irritants. Outlined in the dusk, the silhouette was a prepossessing figure from the road. Up close, it was clear even in the advancing night that the paint was flaking, the plastic scraped and worn.
Bushwhacking our way back to the car in the dark, our guide remarked, “maybe we weren’t supposed to climb these fences.”
The freeway was dark, indistinguishable from the rest of our surroundings. No lamps lit the roadway, and there were few cars or trucks shining their headlamps through the summer night. We drove through the night in silence, occasionally irradiated by the headlamps of oncoming cars. Our guide’s face was thoughtful. The steppe was crossed with shadows in the moonlight.
When he broke the silence, his voice was hesitant, and quiet. Music was an important part of Mongolian culture and communication, he told us. Since we had asked so many questions about inner Mongolia, and about the people, he wondered if we would like to hear some traditional Mongolian songs?
We would.
His voice was surprisingly beautiful, pitched high and clear, with a deep expression and wide range. In the deepening night, with the dim luminance of the moon and the dashboard lights, the sound was mesmeric, soothing, compelling.
In the silence after the song, I felt the rising melancholy of homesickness, coupled with the strange sensation of being precisely where I belonged.
As we re-entered the city, D. received a phone call from his wife. He spoke with her for a few minutes, and then asked us if we had enough time to see some famous temples in the city. His wife had admonished him. “Who wants to see a hole filled with water? You should have taken them to the monastery!”   As you may have divined, the temples had all been destroyed during the cultural revolution, but had been rebuilt to the exact specifications of a new thing that looks just as busted as it would look were it actually to have decayed over millennia.
His entire family was waiting there to welcome us.
D. looked anxiously over his glasses at us. His son, who had inherited the squat frame of his father, was uninterested in school. His grades were not good, and he insisted he wanted to be a famous basketball player. Maybe we could talk to him? If he were to meet some foreigners, perhaps he would become more interested in learning English?
His wife escorted us all over the temple. The night was clear and warm, and the public square was crowded with people. We posed for several pictures with the family, and talked with the son, and coaxed the daughter, who was terrified of us.
As it grew later, the family drove us home in the cab. They refused to accept any payment beyond the fifteen dollars we had paid earlier in the day, which would barely cover our host’s rent to the cab company,  let alone the gas. “Maybe someday,” D. said wistfully, “If I can ever visit America, someone will show me their city, too.”
I thought,
Good luck, pal.
It beggars belief that out there in the world there are more than a scant handful of people who would, with a family to feed, abdicate an entire afternoon of income to spend eight hours showing two strangers the sentimental landmarks of their dreamy childhood; who would turn a stale, contrived burlesque of a temple into a warm, joyful family outing; who would volunteer the depth and breadth of their memories, experiences and tradition in the service of promoting education and understanding; who would modify their curiosity with a superhuman exertion of tact; who would, in light of a broken radio, sing the haunting lullabies of their babyhood in the weak light of an aging cab, a single speeding pool of light on a long, dark, unbroken road.
And please recall that he was out of pocket for several kinds of bread.
So if you ever come across this gentleman, out there in the world, marshal whatever forces you have at your disposal to conquer any baseness or selfishness or impatience in your nature. Set aside your daily concerns, defer some pressing obligations, and spend one afternoon treating a stranger to a personal guided tour of a place you grew up loving. Do it for me. Do it for Karma. Do it in the spirit of building international relations. Or just do it because nothing can approach the experience of encountering, in a howling wilderness, the lesson that ordinary people can have the extraordinary effect of becoming the kindest person you have ever met.